Sr. Medical Rec Coding Spclst

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Job Title:
Sr. Medical Rec Coding Spclst

Department:
Health System Shared Services MIM CDI and Coding

Scope of Position  

Coding services assigns diagnosis and procedural codes to inpatient and outpatient medical records to facilitate the reimbursement and data collection for the individual business units of the OSU Health System. 

ICD-10-CM/PCS diagnoses and procedure codes are applied to inpatients and CPT-4 procedure codes are applied to all outpatients treated within the OSU Health System that are not captured through the charge description master.  Medical record abstract data is assigned based on information reviewed for accuracy in IHIS during the coding process.   

Position Summary  

The position is responsible for coding medical records and other documents at the conclusion of the patient’s visit.  A senior medical records coding specialist requires the skill set to code multiple work types for inpatient and outpatient services (outlined below).  This requires selection of appropriate admitting diagnosis, principal and secondary diagnoses, principal procedure and secondary procedures; assigning accurate ICD-10 and/or CPT-4 codes; sequencing the diagnoses and procedures codes; and abstracting information including admission source, type, disposition, admitting, attending and procedure attending physicians. 

Codes are selected in the Computer Assisted Coding/Encoder Software following review of information in the electronic medical record system, IHIS.  Information abstracted and coded is interfaced to IHIS Resolute Billing system. This staff member is responsible to address all edits during the coding and abstracting process for complete and accurate coding and MS-DRG and APR-DRG assignment for hospital reimbursement.

This staff member will maintain productivity and quality standards set for the department maintain an approved work schedule and submit a weekly volume log.

Duties and Responsibilities  

85% of time –

• Reviews operative reports, progress notes, dictated reports, pathology reports, cytology reports, x-ray reports, laboratory reports, and other medical record information by accessing the electronic record via IHIS
• Reviews record to confirm the findings from the reports prior to coding.
• Confirms admitting diagnosis, principal and secondary discharge diagnoses and operations and procedures, if applicable.
• Prioritizes diagnoses and procedures to ensure complete and accurate coding and/or MS-DRG or APR-DRG assignment or other outpatient payer requirements to optimize hospital reimbursement, research and planning.
• Acts as a liaison with physicians to ascertain and correct information needed to resolve discrepancies regarding diagnoses and procedures.
• Proficient in utilizing Computer Assisted Coding
• Ensures that the health system is compliant with rules for assignment of all appropriate coding/claim modifiers for outpatient encounters. 
• Review all emergency department accounts of patients who were admitted or in Observation and assigns a procedure level charge if warranted.
• Reviews charges as necessary in order to decipher the correct procedure date or determine where to look for additional information to code.
• Reviews abstracted data elements such as patient information, dates of service, point of origin, discharge disposition and attending provider and makes the necessary changes in IHIS.
• Assigns MS-DRG and APR-DRG using grouping software.
• Sends coding queries to providers for clarification on documentation to ensure the most accurate codes

10% of time –

• Performs other routine clerical tasks relating to coding and abstracting.
• Sorts electronic coding work queues for charts to be coded each day and prioritizes by charge amount and date of discharge.
• Substitutes for other personnel as required.
• Investigates and corrects coding discrepancies as a result of quality improvement reviews or system edits.
• Performs other coding related duties per supervisor’s instructions as needs arise.
• Attendance and participation in coding meetings, monthly and annual coding assessment, maintaining productivity and quality metrics.
• Provides cross training when necessary.
• Researches for information regarding changes or updates to coding procedures/requirements.
• Answers ongoing coder questions and listens to problems/concerns and offer suggestions or solutions.

5% of time per month-

• Maintains inpatient senior medical records coding status by coding accounts in three of the five worktypes
• Maintains outpatient senior medical records coding status by coding accounts in four of the five worktypes

Organizational Expectations  

Practices within the Health System’s policies and procedures. Adheres to the Medical Center’s values as demonstrated by striving for excellence, collaborating as One University, demonstrating integrity and personal accountability, openness and trust, promoting diversity in people and ideas, change and innovation, simplicity in our work, empathy and compassion, and leadership. 

Complies with the AHIMA Code of Ethics and Standards of Ethical Coding . Complies with the Department of Medical Information Management’s Standards of Conduct on Billing and Coding .

Minimum Qualifications for hire or promotion

For hire or promotion:

• Minimum completion of a CAHIIM approved coding certificate program or HIMT program or equivalent education & experience
• Demonstrated coding proficiency through the completion of OSUWMC’s coding test.
• Familiarity or experience with computer assisted coding and/or automated encoder.

Inpatient:

• Required: Associate’s Degree in Health Information Management, and a minimum of 1 year inpatient coding experience that include the following service lines: cancer, transplant, obstetrics, rehabilitation and cardiology.
  • For promotion: ability to code at least 3 of the 5 inpatient service locations: University Hospital, University Hospital East, James Cancer Hospital, Ross Heart Hospital and Dodd Rehabilitation Hospital.

OR

• Required: 3 years’ acute care academic medical center inpatient coding experience within an academic Health Information Management department (service lines must include cancer, transplant, obstetrics, rehabilitation and cardiology).
  • For promotion: ability to code at least 3 of the 5 inpatient service locations: University Hospital, University Hospital East, James Cancer Hospital, Ross Heart Hospital and Dodd Rehabilitation Hospital.

AND

• Required: Credentialed as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS) by the American Health Information Management Association.

Outpatient:

• Required: Associate’s Degree in Health Information Management, and a minimum of 1 year outpatient coding experience (ICD10CM and CPT) for service types such as emergency, outpatient, ambulatory surgery, observation and series/clinics.
  • For promotion: ability to code at least four outpatient service types (ASU, observation, emergency, outpatient and series/clinics).

OR

• Required: 3 years’ acute care academic medical center outpatient coding experience within an academic Health Information Management department for service types such as emergency, observation, outpatient, ASU and series/clinics.
  • For promotion: ability to code at least four outpatient service types (ASU, observation, emergency, outpatient and series/clinics).

AND

• Required: Credentialed as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist by the American Health Information Management Association, or Certified Outpatient Coder (COC) by AAPC

Certification

• RHIA, RHIT, CCS, or COC (outpatient credential only)

On Going:  

• Maintain continuing education requirements as determined by the American Health Information Management Association or AAPC.  Review Coding Clinics, CPT assistant as frequently as needed for education purposes, and to ensure the official coding guidelines are followed. 

• The senior medical records coder attends monthly coding meetings and coding education sessions for updates on coding guidelines and related issues while maintaining a minimum score of 90% on coding assessments.

Additional Information:

Location:
Remote Location

Position Type:
Regular

Scheduled Hours:
40

Shift:
First Shift

Final candidates are subject to successful completion of a background check.  A drug screen or physical may be required during the post offer process.

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